Учебники / LECTURE NOTES ON Diseases of the Ear, Nose and Throat Bull 2002

Fig. 28.1 The appearance of the tonsils in glandular fever.

caused by a specific toxin. It is characterized by a punctate erythematous rash, circumoral pallor and a‘strawberry and cream’ tongue.

Diphtheria

Diphtheria still occurs on rare occasions in the UK and should be considered in recent travellers to India or the former USSR. It is of insidious onset and characterized by a grey membrane (difficult to remove) on the tonsils, fauces and uvula. Pyrexia is usually low and diagnosis is confirmed by examination and culture of a swab.

Agranulocytosis

Agranulocytosis is manifested by ulceration and membrane formation on the tonsils and oral mucosa.The neutropenia is diagnostic.

HIV

Patients with impaired immunity from HIV infection are particularly at risk of pharyngitis and ulcerative tonsillitis.

TREATMENT OF ACUTE TONSILLITIS

1Rest — the patient will usually prefer to be in bed.

2Soluble aspirin or paracetamol held in the mouth and then swallowed eases the discomfort. Remember that aspirin should not be given to children under the age of 12 years because of the risk of Reye’s syndrome.

3Encourage the patient to drink or she/he will easily become dehydrated.

4Antibiotics in severe cases. Penicillin by injection followed by oral treatment remains the treatment of choice. It is recommended that treatment be continued for 10 days to reduce the risk of reactivation.

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There is no place for antiseptic or antibiotic lozenges, which may predispose to monilial infection and are in any case ineffective.

COMPLICATIONS

1Acute otitis media (the most common complication).

2Peritonsillar abscess (quinsy).

3Pulmonary infections (pneumonia, etc.).

4Acute nephritis IgA nephropathy.

5Acute rheumatism.

Peritonsillar abscess (quinsy)

CLINICAL FEATURES

A quinsy is a collection of pus forming outside the capsule of the tonsil in close relationship to its upper pole.The abscess occurs as a complication of acute tonsillitis, but is more common in adults than in children.

The patient, already suffering from acute tonsillitis, becomes more ill, has a peak of temperature and develops severe dysphagia with referred otalgia. On examination, a most striking and constant feature is trismus; the buccal mucosa is dirty and foetor is present.

The anatomy of the buccopharyngeal isthmus is distorted by the quinsy, which pushes the adjacent tonsil downwards and medially.The uvula may be so oedematous as to resemble a white grape.

TREATMENT

Systemic penicillin must be given without delay, and in very early cases with ‘peritonsillitis’ only, abscess formation may be aborted. If much trismus is present and the presence of pus strongly suspected, incision is indicated, for without this, spontaneous rupture may be long-delayed.

If the diagnosis is correct, the patient will spit out pus and some blood, and the relief from former misery is immediate and dramatic.

In children, the drainage of a quinsy should be performed under general anaesthesia; great skill and care are called for to avoid premature rupture of the quinsy before the airway is safeguarded.

Following quinsy, it is conventional to carry out tonsillectomy 6 weeks later. If there has been no previous history of tonsillitis this may not be necessary.

Recurrent acute tonsillitis

Most people will at some time experience acute tonsillitis, but some indi-

114Chapter 28: TheTonsils and Oropharynx

viduals are subject to recurrent attacks, especially in childhood. Between attacks the patient is usually symptom-free and the tonsils appear healthy. If such attacks are frequent and severe, tonsillectomy is advisable. It is important before arriving at such a decision to be sure that the attacks are truly acute tonsillitis, with the features listed earlier. If there is doubt, it is helpful to ask the patient (or the parents) to document the attacks over a period of several months. If there are contraindications to operation, e.g. a bleeding disorder, long-term prophylaxis with oral penicillin may reduce the frequency and severity of attacks.

Tonsillar enlargement

As a general rule, the size of the tonsils is immaterial. Many parents are concerned about the size of their offspring’s tonsils but can be reassured that no treatment is necessary unless the child is subject to recurring attacks of acute tonsillitis.

There is, however, a small number of children in whom the tonsils and adenoids are enlarged to a degree that makes eating difficult and endangers the airway. Such children are dyspnoeic even at rest, mouth breathe, snore and are prone to episodes of sleep apnoea. Right heart failure may ensue.

A timely operation to remove the tonsils and adenoids from such a child will result in a dramatic improvement in health.

Acute pharyngitis

Acute pharyngitis is exceedingly common, and probably starts as a virus infection. It is often associated with acute nasal infections.

The symptoms consist of dysphagia and malaise and, on examination, the mucosa is found to be hyperaemic.

As a general rule the treatment of acute pharyngitis should consist of regular analgesics, such as aspirin 4–6-hourly. Unhappily, this complaint is frequently treated by course after course of oral antibiotics, often aided and abetted by antibiotic or antiseptic lozenges. As a result, the flora of the mouth and pharynx may be disturbed completely and moniliasis ensues, with the net result that after 6 weeks of treatment little or no progress has been achieved.

Chronic pharyngitis

Chronic pharyngitis produces a persistent though mild soreness of the throat, usually with a complaint of dryness. Examination shows the pharynx to be reddened and there may be enlargement of the lymphoid nodules on

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the posterior pharyngeal wall — granular pharyngitis.There may also be present lateral bands of lymphoid tissue alongside the posterior faucial pillars.

Predisposing factors that should be looked for are:

1smoking or excessive indulgence in spirit drinking;

2mouth breathing as a result of nasal obstruction;

3chronic sinusitis;

4chronic periodontal disease;

5exposure to harmful fumes, usually industrial;

6use of antiseptic throat lozenges.

TREATMENT

If any of the causes listed are present, appropriate action will be beneficial. If the lymphoid aggregates on the posterior wall are prominent, treatment by diathermy or cryosurgery may help.

Malignant disease of the tonsil and pharynx

Carcinoma

Carcinoma will present as painful ulceration with induration of the tonsil, fauces or pharyngeal wall. It is often accompanied by referred otalgia and slight bleeding. Lymphatic spread to the upper deep cervical nodes is early. Diagnosis is confirmed by biopsy of the tonsil.

Lymphoma

Lymphoma of the tonsil tends not to ulcerate, but produces painless hypertrophy of the affected tonsil. Tonsillectomy as an excision biopsy is indicated without delay in such a case.

TREATMENT

Treatment of carcinoma is by radical excision usually followed by external irradiation, and of lymphoma by chemotherapy and/or radiotherapy. The prognosis of carcinoma is poor but for lymphoma will depend on its cellular nature, some types having a very good prognosis.

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obtained by ligating the bleeding vessels. If the adenoids are to be removed at the same operation they are usually dealt with first.

POST-OPERATIVE CARE

The patient will be kept in the recovery area adjacent to the operating theatre until fully conscious. It is vital to ascertain that all bleeding has stopped before being returned to the ward.

Once back on the ward, pulse and blood pressure are checked frequently. The pulse should be taken every half hour for the first four hours and then hourly until discharge. The patient is observed meticulously for any sign of bleeding or airway obstruction.

The care of post-tonsillectomy patients calls for a high degree of vigilance and must never be delegated to inexperienced nurses.

Several hours after operation, most patients are able to take oral fluids but should avoid blackcurrant cordial, which if vomited may look like blood.

After operation, the temperature should be recorded 4-hourly and any rise noted. Pyrexia may be due to local infection, to chest or urinary infections or to otitis media.

Although earache is common after tonsillectomy and is usually referred from the tonsil, do not omit examination of the ears.

The appearance of the tonsillar fossa often gives rise to alarm. Within 12 h it is covered with a yellowish exudate, which persists for 10–14 days. It is quite normal and does not indicate infection. It is not pus.

Following tonsillectomy, as normal a diet as possible is to be encouraged. Analgesics, such as soluble paracetamol prior to eating, are helpful. Eating normal food usually produces a reduction in pain afterwards (though not at the time!).

COMPLICATIONS OF TONSILLECTOMY

Reactionary haemorrhage

The major risk from tonsillectomy is that of haemorrhage. Indications of reactionary haemorrhage are:

1a rising pulse rate, though the blood pressure may remain constant initially;

2a wet, gurgling sound in the throat on respiration, which clears on swallowing;

3sudden vomiting of altered or fresh blood, which is often accompanied by circulatory collapse;

4obvious bleeding from the mouth.

Post-operative bleeding must be stopped urgently and delay may be fatal. Blood must be cross-matched and a drip set up. In a cooperative patient the

bleeding may be arrested by the careful removal of clot, followed by pressure from a rolled-up gauze held in forceps. Usually, however, a return to theatre without delay is called for especially in children, when the bleeding point can be identified and ligated.The anaesthetic for such a procedure is hazardous and should not be delegated to a junior anaesthetist.

Secondary haemorrhage

Secondary haemorrhage occurs between the fifth and tenth postoperative days and is due to fibrinolysis aggravated by infection. Such bleeding is rarely profuse but the patient should be readmitted to hospital for observation. Usually the only treatment required is mild sedation and antibiotics, but an intravenous line should always be set up and the blood saved for grouping. It is only rarely necessary to return the patient to the operating theatre to control the bleeding.

Otitis media

Otitis media may occur following tonsillectomy — earache is not referred pain until you are sure the ears are normal.

Infection

Infection may occur in the tonsillar fossae and is marked by pyrexia, foetor and an increase in pain. Secondary haemorrhage is a potential danger and antibiotics should be given.

Pulmonary complications

Pulmonary complications such as pneumonia or lung abscess, are rare and may be caused by inhalation of blood or fragments of tissue.

Fig. 30.2 Retropharyngeal abscess in an adult secondary to a foreign body.

TREATMENT

Antibiotics should be given in full doses.

Incision of the abscess should be carried out without delay. General anaesthesia is advisable but requires great skill and gentleness — rupture of the abscess may prove fatal as a result of aspiration of pus. The abscess is incised through the pharyngeal wall and pus sent for bacteriological examination.